The paperwork standard of care: medical malpractice liability for violating advance directives
Hospital and physician liability for saving the life of someone who wished not to be saved is an area of evolving law. While years ago, such cases were routinely dismissed, recent caselaw recognizes the cause of action under medical malpractice. Increasing public awareness of the importance of advance directives and movements like medical aid in dying, palliative care, and hospice suggest that people wish to have more control over the circumstances surrounding the end of their lives and their death. Arguably, the encouragement to create advance directives brings with it a responsibility to honor them. The law has not caught up for now and courts litigating the medical malpractice lawsuits asserting harm from a prolonged life have little and mixed precedent. Further muddying the water is that some of the relevant caselaw comes from claims that involve the refusal of blood transfusions for religious reasons by Jehovah’s Witnesses. While the ability of adults to refuse care is settled law, whether the failure to go along with a directive can or should lead to liability varies across courts and jurisdictions and is far from settled, both in ethics and law. This article looks to how and why directives differ and to whether any law can navigate the differences and come to an equitable conclusion about liability under medical malpractice law.
Medical malpractice and advance directives
The four elements of medical malpractice generally are that the healthcare provider has a duty to the person, the provider breached the duty (usually by failing to meet the accepted standard of care), proximate cause, and injury. Whether following a directive is always a standard of care and whether failing to follow one is always a departure from the standard of care is unclear. Courts have used this technicality to decide whether a medical malpractice cause of action exists. But here courts are establishing what I call “the paperwork standard of care” and applying it in cases where the patient is elderly or terminally ill. To say the standard is to follow the directive implies following the directive of a religious refuser or, theoretically, a young, healthy refuser would be the standard of care as well.
Normally, the standard of care refers to treatment, like recommending chemotherapy for certain cancers or prescribing antibiotics for certain infections. (Hospitals do have other areas where they must meet a standard of reporting requirements or privacy considerations, or informed consent documentation.) In the Jehovah’s Witness cases, courts have looked to the medical standard of care and older cases have held that doctors who give (nonconsensual) blood transfusions are following the standard of care (to transfuse or to perform other services, even those that carry the risk of blood loss) and therefore not liable under medical malpractice law. The different treatment of the same element of malpractice (a duty to defer to the directive) cannot be easily reconciled unless it is placed in the context of the type of refusal, age and medical conditions of the refuser, and the religious background, etc.
(As background, the refusal of blood has changed both as the Jehovah’s Witness organization is more open to forgiving members that have transfusions, the belief itself may be devolving, and there are alternative products that can stop bleeding or improve clotting, decreasing the risk of refusing blood. Nonetheless, relatively recent Jehovah’s Witness deaths during childbirth and accidents demonstrate the ongoing need to address disparate treatment of overriding directives.)
Constitution, liberty, and exceptions
Although the right to refuse is established, it is not absolute: for example, adults’ wishes may be challenged on grounds of lack of capacity and competence and states may have procedures governing the requirements for exercising the right, even posing some procedural barriers. In some states, pregnant women have been kept on life support to sustain fetal life against their wishes as expressed by directive or surrogate. A state interest in protecting life and arguably preventing suicide limits the right of an adult to refuse medical care. Still, directives are the best way to chronicle wishes and to direct one’s own medical care in the case of incapacity or unconsciousness. The right to refuse and the right to self-direct medical care would become meaningless if doctors were never held liable for violating directives.
And the broader, theoretical aspects will continue to plague the courts: there is no age or medical criteria for distinguishing whether ignoring a directive or following one is the standard of care. Doctors might even be more likely to override a young person’s directive, both intentionally and by mistake. It is inappropriate and impractical to expect hospitals and doctors to investigate and judge the reasons for the directive as doctors and courts both are not expected to make life’s most precious decisions for others. If anything, the purpose of the directive is to preclude the need for background or guesswork. Beyond religion, a young person who has no interest in continued life could have a living will or other directive to avoid resuscitation, but a hospital might avoid facilitating a DNR order based on a seemingly irrational directive. The push for advance directives implies a preference for more detailed ones and simply more people having one. There is the expectation that some people wish to avoid circumstances like paralysis, vegetative states, memory impairment, or the need to rely on feeding tubes, devices, or heavy sedation for pain, primarily with no hope of recovery. Yet considering the application of medical aid in dying to young people and people with mental but not non-medical illness, an observable slippery slope could apply to directives. Should overriding a directive be an actionable breach of duty only if a terminally ill or elderly person created the directive? Only if the person did (or did not) have religious reasons for the directive? Only if the directive is what is perceived as reasonable? The worst case would be that directives are respected when doctors approve of them based on the patient’s circumstances and not when they do not, the scenario the law is attempting to prevent.
The paperwork standard of care also implies that there is an obligation to be aware of any directives, posing challenges in emergency settings.
Medicine as care, cures, and treatments
Medical ethics, practices, and laws reflect autonomy and respect for adult decision makers. Traditionally, doctors and hospitals were in the business of curing patients or treating disease. In that paradigm, the shared goals of doctor and patient were focused on survival, not on desirable circumstances of death. The new paradigm of medicine includes palliative care and hospice, and many doctors see honoring patients’ wishes and encouraging comfort care rather than curative care part of their professional responsibilities. But the emergence of hospice, palliative care, and medical aid in dying cause a tension between old and new approaches and between interests in life or suicide prevention and a person’s autonomy. Ethicists and the law distinguish between removing life-saving technology and suicide and between failure to provide care and assisting suicide. Nonetheless, some directives will pose more ethical challenges for doctors than others.
When patients refuse care, arguably their underlying disease or injuries cause death. In the case of competent, terminally ill patients, the physician’s ethical duty to save a life through medical care is not applicable. In the case of the religious refusal or the refusal by someone who is young and healthy, the absence of care may play a more predominant causal role in a death, placing a distinctly different burden on the physician who must hold back care to follow the directive. Generally, the clearest ethical (rather than legal) obligation to recognize a directive occurs when the care withheld would only prolong dying and subject the patient to additional pain and suffering. But absent those conditions, honoring a directive may be at odds with a physician’s training, ethos, and self-determined ethical duty to save lives. When the treatment would be curative, doctors may hesitate to honor a directive not to treat if a person were temporarily incapacitated.
The ethical dilemmas caused by following directives reflecting religious refusals by healthy, young people and those reflecting refusals by terminally ill people differ considerably. For example, if in one case an elderly person has set forth her wishes (through advanced directive and DNR order) and, in another, a young, healthy religious person has set forth hers (for example, a blood transfusion refusal case), the outcome of a failure to honor the directive could differ. In the case of the older adult, the legal instrument would be an advance directive saying not to resuscitate and a DNR order would likely be placed in her chart. In the case of the young religious refusal, the directive would say not to give a blood transfusion and that the person means to refuse to accept any blood transfusion even if the refusal would result in death. What the patient is asking of the medical practitioner is different: in one case to avoid or prevent pain, suffering, and mental or emotional harm, in the other to avoid an abstract, religious-based, potentially mental and emotional harm and, in either case, by omission allow for death. It is unclear ethically or legally whether following the directive should be the standard of care considering cases where mental and emotional harm of continued living is a possible compensable harm.
Statutes, immunity, and causes of action
An adult can designate a health care proxy to make decisions under the Health Care Proxy Law. New York’s Family Health Care Decisions Act (FHCDA) specifies strict criteria for surrogates to authorize withholding life-saving treatment or withdrawing life support. (The FHCDA steps in to appoint a surrogate (ideally, a family member) to make decisions when there is not a health care proxy.) However, New York also offers wide latitude to adults to make specific living wills. In New York, “If you are 18 years of age or older, you may express your wishes in writing about your health care by signing a Living Will.” Adults have leeway to write their living will as they wish and to assign a health care proxy who knows their wishes or whom they trust to make decisions. Living wills guide care while MOLST forms and DNR orders become part of the orders in a patient’s medical chart. In New York, a MOLST form is used by hospitals to record wishes and is a formal record of preferences for life sustaining care. The MOLST form is specific:
To implement a patient’s wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment, facilities may, if appropriate, utilize the department approved MOLST form for patients with serious health conditions who:
(1) want to avoid or receive any or all life-sustaining treatment; or
(2) can reasonably be expected to die within one year.
A DNR order is also part of the medical record recorded by a hospital. The regulation implies the MOLST form could not apply to people without a serious health condition.
New York’s Family Health Care Decisions Act provides immunity for honoring a surrogate’s decision, but not for disregarding one, and allows doctors to conscientiously object as long as they notify the patient that they do not intend to follow the directive, something difficult in emergencies or with unconscious patients. The Family Health Care Decisions Act governs surrogates rather than properly executed directives in the absence of a surrogate decision maker, but it does set valuable parameters. The advance directives law covers procedures for acknowledging directives and patient education, especially in nursing homes. Hospitals and nursing homes can seek clarification by courts to determine whether directives are clear and convincing, yet in emergencies, that is not a practical approach.
Many states have enacted similar laws, but none quite cover the exact situation either by offering complete immunity for overriding directives or by establishing and guaranteeing a statutory cause of action against hospitals and doctors who override or ignore advance directives. The state laws attempt to navigate the space using immunity clauses, but they require doctors to notify the patient or family if they plan to override a DNR (conscientious objection clauses) so that the family can seek care elsewhere. Once they ignore the DNR and rescue the patient without forewarning them, the immunity does not apply.
In keeping with states’ ability to put procedural requirements on the proof needed to clarify one’s wishes, one open question is whether some advance directives should be deemed unenforceable, making the medical malpractice element of a breach of duty no longer dependent on whether the doctor honored the directive or not. Yet, of course, obvious constitutional problems would stem from declaring religious advance directives and advance directives that refuse life-saving care for no apparent reason (or for a financial reason) void. The problem is not widespread, and you might wonder whether there is a problem. (Most of the time, there would not be!) But the growing number of directives and the acknowledgement that people want to control the circumstances of their death may bring an increase in the cases of paperwork that demands physicians to do less in circumstances where their own morals compel them to do more. In such circumstances, if there are valid directives and the patient clearly wanted to not be resuscitated or refused life-saving care, following the directive may become the standard of care as categorically ignoring it cannot be.
Concepts and cases: Wrongful life and DNR violations
Wrongful life tends to refer to a cause of action against doctors and hospitals when people continue a pregnancy to birth based on erroneous diagnostic reporting. For example, in Alquijay v. St. Luke’s Roosevelt Hospital Center, a plaintiff sued after giving birth to a baby with Down Syndrome arguing that she would have terminated the pregnancy. They blamed negligence in the amniocentesis. The courts want to keep out of such cases as the parents are asking them to compare nonexistence to living with a condition. In Becker v. Schwartz, a New York judge said damages “demand a calculation … dependent upon a comparison between the Hobson’s choice of life in an impaired state and nonexistence, which the law is not equipped to make.” Yet in many states special damages to cover the costs associated with raising a child who needs more medical care or devices is attainable. The inability of a child to sue asserting the harm of life rests on the absence of a legal right not to be born. Yet some states recognize a cause of action when an error or negligence deprives parents of making an educated decision about terminating or continuing a pregnancy. There is high variance among states in the arena of wrongful pregnancy, wrongful birth, and wrongful life.
Directives are different. There is a fundamental right to direct one’s own medical care. Directives can include refusal of life-sustaining care, to which there is an established right. In fact, that may be when they are the most informative, useful, and reflective of a person’s philosophical and ethical views on quality versus quantity of life.
In Cronin v. Jamaica Hospital Medical Center, a New York appellate court (Second Dept) held that the status of being alive is not harm. On two occasions, a man was resuscitated in violation of DNR orders executed by both the hospital and his family. The court found that because the plaintiff did not claim an injury other than wrongful prolongation of life occurred, no injury resulted, yet the Cronin case left the door open to other claims of harm or injury.
In 2012 in Georgia, a 91-year-old grandmother, Bucilla Stephenson, was placed on a ventilator in violation of her advance directive and her granddaughter’s instructions as healthcare proxy. Stephenson initialed the end-of-life option that stated:
I do not want my life to be prolonged if (1) I have an incurable[ ] and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits.
Jacqueline Alicea, Stephenson’s granddaughter, claimed “breach of agreement, professional and ordinary negligence, medical battery, intentional infliction of emotional distress, and breach of fiduciary duty.” Prior to settlement, the Supreme Court of Georgia affirmed the denial of summary judgment, holding that the hospital and doctor were not entitled to immunity. The Georgia court relied on the relevant statute which honors the decision of the appointed healthcare agent over the directive, and honors both over the decision of the medical professionals. Here, the granddaughter was acting in accordance with the advance directive, seemingly the strongest position. The doctors would have some limited ability to override an agent or directive’s refusal of pain care or to conscientiously object to following a directive, an exception requiring prompt notification to the health care agent. The court relied on the immunity provisions in the Georgia statute, holding they did not apply generally to practitioners who ignored a directive, but specifically to those acting in good faith and those following the proper procedures to conscientiously object. Additionally, the hospital did not follow its own policies on advance directives. The case settled for $1 million.
In 2013, medical staff at Maryland General Hospital (also known as University of Maryland’s midtown campus) resuscitated Beatrice Weisman in violation of her directive and a MOLST order clearly stating that she be allowed to die if her heart or lungs failed. (In Maryland, MOLST orders are part of the medical record, and they are entered as physician’s orders.) Her son, Christian filed a complaint which alleged many causes of action: assault, negligence, intentional infliction of emotional distress, breach of contract, breach of fiduciary duty, and lack of informed consent. The family cared for her for many years – she died in 2020, after years of expensive care provided at her home. The case settled for an undisclosed amount.
In 2016, a Montana hospital resuscitated Rodney Knoepfle in violation of his DNR and DNI (do not intubate) orders. His orders were entered upon his admission to the hospital. The patient, who died two years later, sued. After his death, his wife, Cheryl O’Donnell continued the lawsuit as executor. The lawsuit alleged tortious violation of the lawfully binding orders which were entered by physicians into the medical orders. The hospital failed to protect him from unauthorized care in violation of standard procedures, or what I refer to as the paperwork standard of care. The lawsuit focuses on hospital shortfalls like a lack of procedures, training, and consistency in honoring directives. The claim uses the word “uniform” throughout, indicating that the plaintiff expects a standard across the board rather than any disparity between orders or patients. This case resulted in a jury award of $200,000 in compensatory damages and $209,000 for pain and suffering. The pain and suffering included the mental and physical pain associated with the unwanted prolongation of life.
In New Jersey, an 89-year-old was resuscitated in violation of her DNR and DNI order when she went into cardia arrest during a surgery. In the case, Koerner v. Bhatt, a New Jersey court denied summary judgment and held that the New Jersey Advance Directive for Health Care Act did not grant immunity to doctors or hospitals ignoring directives but would apply to doctors and hospitals who are sued for following directives. The court delved into the relationship between wrongful pregnancy and birth and wrongful prolongation of life, adding consistency to the state’s approach to recognizing injury in the pain and suffering associated life, rather than in the mere presence of life. The case settled for an undisclosed amount.
In New York in 2016, a 63-year-old with advanced Alzheimer’s disease who was unable to recognize his family members or to communicate meaningfully was admitted to Montefiore New Rochelle Hospital. His son executed a MOLST form upon arrival at the hospital. The form indicated the patient was DNR and DNI and was to receive comfort care only, no antibiotics, tube feeding, or IVs. A doctor knowingly ignored the order after confirming the directive with the patient’s son. As a result, the patient endured pain and suffering for 30 days before dying.
The plaintiff filed a medical malpractice case, Greenberg v. Montefiore New Rochelle Hospital, asserting the doctor and hospital deviated from the standard of care by failing to follow the patient’s advance directives, the directives of his agents, and the MOLST form.
When considering summary judgment, the Greenberg court held that the case is distinctly unlike the wrongful life cases like Alquijay. In the case of ignoring the orders, the harm is calculable. The court stated that juries do assess pain and suffering regularly and that “no philosophical guesswork is required as to what is best for such a patient.” In comparing the case to Cronin, the court held that this medical malpractice claim was not barred by the wrongful prolongation of life claim the court did not accept in Cronin. Greenberg has yet to go to trial or settle.
Jehovah’s Witness religious refusals
Over time, cases in which doctors overrode the refusals of blood by Jehovah’s Witnesses evolved from protecting doctors to requiring doctors to respect religious refusals of competent adults. In 1965, a Connecticut court held that people cannot demand mistreatment (U.S. v. George) and in 1985 in Crouse-Irving v. Paddock a New York court noted the dilemma of a patient requesting care that carries the risk of blood loss while refusing blood transfusions. The Crouse-Irving court cited Matter of President Directors of Georgetown Coll.: “A third set of considerations involved the position of the doctors and the hospital. Mrs. Jones was their responsibility to treat. The hospital doctors had the choice of administering the proper treatment or letting Mrs. Jones die in the hospital bed, thus exposing themselves, and the hospital, to the risk of civil and criminal liability in either case. It is not certain that Mrs. Jones had any authority to put the hospital and its doctors to this impossible choice. The normal principle that an adult patient directs her doctors is based on notions of commercial contract which may have less relevance to life-or-death emergencies. It is not clear just where a patient would derive her authority to command her doctor to treat her under limitations which would produce death.”
Over the years, it became standard to allow adults to refuse blood transfusions, based on caselaw (Cruzan especially delineated the right to refuse) and growing patient autonomy movements. Nonetheless there are some relatively recent instances of doctors overriding documented religious refusals. In DiGeronimo v. Fuchs, Nancy DiGeronimo received a blood transfusion without her consent after bleeding persisted after childbirth. She brought a medical malpractice claim in which the harm was wrongful life. The case in the end looked to whether the doctor violated the standard of care in choosing a vaginal delivery rather than a caesarian delivery, which she alleged caused the need for the transfusion, which led to her allegedly wrongfully living. The plaintiffs did not assert that the standard of care was to honor the religious refusal. But the case is relevant considering the DNR cases, and religious and other refusers may take the route of alleging a deviation from the paperwork standard of care, improving their ability to demonstrate medical malpractice. The DiGeronimo court also held that Alquijay was not controlling. The ability to put a price on the emotional pain and suffering due to the violation of her religious beliefs is something a judge or jury can grapple with. The court distinguished continued life from the Hobson’s choice described in Becker and Alquijay.
In Williams v. Bright, a plaintiff who had refused treatment and survived, sued a car-leasing agency for negligence. The appellate court said, “the real issue here is whether the consequences of [her religious belief] must be fully paid for here on earth by someone other than the injured believer.” While cases have become more nuanced, courts grapple with the role of religious refusals in contributing to injury or death.
Rare but possible
If a healthy 18-year-old had a directive that refused life-sustaining care for no apparent reason, an emotional reason, a reason of conscience (like not wanting to use healthcare resources), or a strong anti-medicine stance, there is an open ethical dilemma. A doctor would have some leeway to refuse to follow the directive through conscientious objection, and then under the law, could inform the family in time for a family to move the patient elsewhere. (In emergencies, a transfer can be difficult, impractical, or impossible.) A physician might override such a directive in the moment without using procedures for conscientious objection. The ethical pull to override such a directive would be strong and pose a serious dilemma for doctors, hospitals, and other emergency care providers. The caselaw is unclear about the legal risks of overriding directives as society does have a strong interest in people directing their own care, and especially in permitting refusals of care. It seems easy to understand the cases holding in favor of terminally ill, older adult plaintiffs whose directives were ignored or overridden, subjecting them to pain and suffering. With the caselaw leaning toward liability for wrongly overriding directives, physician decision making could turn toward following directives even when they are seemingly bewildering, absent capacity questions.
Could There Be a Better Rule? Maybe not…
Requirements of an ethically valid directive refusing life-sustaining care could include that a person be terminally ill, not expected to live more than six months, or not expected to regain the quality-of-life parameters that make life worth living to them. (Some would also argue that extreme pain with no solution and extreme psychological pain ethically justify directives that refuse life-sustaining care.) For now, they are not requirements of a legally valid directive. Free exercise of religion and autonomy both justify allowing all adults to have directives, healthy ones primarily for the sake of determining which burdens they would live with, and which circumstances would be so contrary to their views on quality of life that they would prefer not to be saved by medical care. So, it can remain (or become) simply a standard of care issue, in which case following directives is the standard of care. Normally, that should work well. When healthy people create seemingly irrational directives, if the standard of care is to follow the directive, but the physicians wish not to, then conscientious objection or looking to capacity or any limitations on free exercise could allow doctors to override without liability. Returning to the issue of medical malpractice, it really is not yet clear whether a malpractice claim would be mitigated by evidence that the doctor perhaps believed the directive was in error, made without capacity (or without the support of a decision maker, if relevant, as in a case of a cognitive disability), fraudulent, or that there was not time to move the patient to another hospital pursuant to a conscientious objection. It is also unclear whether anyone going in to a medical calamity otherwise healthy and young would have a legitimate claim that they were harmed by being saved.
Conclusion: A Consistent Paperwork Standard of Care
Wrongful continuation of life is becoming a legitimate cause of action under medical malpractice. For now, it requires some harm other than just continued life. Good law should apply to all relevant parties fairly. If liability depends on a deviation from the standard of care, then that law must apply generally to adult directives. In many cases that law would shore up autonomy and allow people to make their own medical decisions in advance through directives. But such a broad law would present ethical problems in some cases: doctors could be liable if they were to save an 18 year old with no preexisting medical conditions and no discernable reason for having the directive or a young, healthy religious refuser. Those cases would likely then turn on harm in jurisdictions where wrongful continuation of life is not recognized. Or the law would need to stipulate that the paperwork standard of care is to follow directives only in certain circumstances. We do not have an objective ethical or practical guidance on when it is morally right to feel bound by a directive and when is it not. Holding physicians or hospitals liable when overriding directives of the sick, terminally ill, people in pain, or those who would need to rely on more support than they find tolerable seems fair and ethical, as the harms of failing to follow the directive are more easily identified in those cases. But any rule that allows doctors to override directives categorically essentially would undermine the very advance directives and living wills that hospitals and states are encouraging everyone to create. As courts begin to allow damages for mental and emotional anguish unrelated to physical pain or financial burden, courts should allow damages for emotional harm from violating a religious practice or belief as well. Eventually, courts may hold that damages for emotional harm even when doctors resuscitate the healthiest 18 year old against her will are justified. Perhaps, to the hospitals and physicians, a lawsuit lost is morally better than allowing a young, relatively healthy person to die. It is not just unclear how far the slippery slope would go, but unclear whether advance directives solve as many ethical issues as bioethicists think they do.
NOTHING HEREIN IS LEGAL ADVICE. THIS PAPER IS FOR INFORMATION, LEARNING, and ENTERTAINMENT.
 Greenberg v. Montefiore New Rochelle Hosp., No. 2022-02194 (N.Y. App. Div. Mar. 31, 2022) (medical malpractice case in which plaintiff alleged breach of duty to provide the standard of care in failing to follow the directive and MOLST; summary judgment denied.) https://casetext.com/case/greenberg-v-montefiore-new-rochelle-hosp-1
 Cruzan v. Director, Missouri Dept of Health, 497 US 261 (1990) (holding there is a liberty interest in refusing medical treatment)
 Cruzan (allowing Missouri to require clear and convincing evidence of the persons wishes.)
 Leo R. J. (1999). Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians. Primary care companion to the Journal of clinical psychiatry, 1(5), 131–141. https://doi.org/10.4088/pcc.v01n0501; State Dept. of Hum. Serv. v. Northern, 563 S.W.2d 197 (TN: 1978)
 Elliston, Sarah. Life After Death? Legal and Ethical Considerations of Maintaining Pregnancy in Brain Dead Women
In Intersections: Women on Law, Medicine and Technology, ed. Petersen, Kerry. Routledge 1997
 New York State, Attorney General’s Office. https://ag.ny.gov/sites/default/files/advancedirectives.pdf
 Lopez, A. B., & Vars, F. E. (2019). Wrongful Living. Iowa Law Review, 104(4), 1921+. https://link.gale.com/apps/doc/A594831642/AONE?u=columbiau&sid=summon&xid=07e84269
 Commentary on New York Medical Aid in Dying Proposal, June 2017 White paper, New York City Bar Association https://www.nycbar.org/member-and-career-services/committees/reports-listing/reports/detail/commentary-on-new-york-medical-aid-in-dying-proposal
 NY Pub Health L § 2981 (Article 29-C)
 NY Pub Health L § 2994-D (2015)
 10 CRR-NY 400.21, Advance directives, New York Codes, Rules and Regulations (effective 03/26/2014) https://regs.health.ny.gov/content/section-40021-advance-directives#:~:text=400.21; New York Attorney General’s Office, Advance Directives: Making Your Wishes Known and Honored https://ag.ny.gov/sites/default/files/advancedirectives.pdf
 10 CRR-NY 400.21, Advance directives, New York Codes, Rules and Regulations (effective 03/26/2014) https://regs.health.ny.gov/content/section-40021-advance-directives#:~:text=400.21
 NY Pub Health L § 2994-O (2015)
 NY Pub Health L § 2994-N (2015); see also Title: Section 400.21 – Advance directives, New York Codes, Rules and Regulations. https://regs.health.ny.gov/content/section-40021-advance-directives#:~:text=400.21
 For example, see Georgia and New Jersey
 NY FHCA Conscience Objections (n) and immunity (o).
 Becker v. Schwartz, 47 N.Y.2d 401 (N.Y. 1978); and see Alquijay v. St. Lukes-Roosevelt Hosp. Ctr., 63 N.Y.2d 978 (N.Y. 1984).
 For example, see Elliott v. Brown, 361 So.2d 546 (Ala. 1978).
 See Berman v. Allen 80 N.J. 421 (1979).
 Schloendorff v. Society of New York Hospital, 105 N.E 92 (N.Y. 1914). “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages.” Judge Benjamin Cardozo.
 Quinlan, Cruzan
 Cronin v. Jamaica Hospital Medical Center N.Y.S.2d (2009)
 Doctors Hospital of Augusta et al. v. Alicea, Administratrix. 299 Ga. 315,788 S.E.2d 392 (2016) https://caselaw.findlaw.com/ga-supreme-court/1741593.html
 Doctors Hospital v. Alicea.
 See OCGA § 31-32-10 (a) (2) and (3).
 “The Court of Appeals rejected this reading of the statute, and so do we. To begin with, as a matter of basic grammar, the text following a colon normally elaborates on the general statement that comes before it, rather than being disassociated from the introductory clause. See William Strunk, Jr. & E.B. White, The Elements of Style (3d ed. 1979) (“A colon tells the reader that what follows is closely related to the preceding clause.”).” Doctors Hospital v. Alicea. https://caselaw.findlaw.com/ga-supreme-court/1741593.html
 Nash, Ryan (2017) Lawsuit Alleges Patients End-of-Life Wishes Ignored, Medical Ethics Advisor.
 Weisman v. Maryland General Hospital, Inc. pleading No. 24-C-16-004199. July 25, 2016. 2016 WL 4010033 (Md.Cir.Ct.) (Trial Pleading) Circuit Court of Maryland. Baltimore City; Complaint at 2, Weisman v. Md. Gen. Hosp., Inc., No. 24-C-16-004199 (Baltimore City Cir Ct, July 25, 2016).
 Hospital ordered to pay $400K in do-not-resuscitate lawsuit, AP, 2019 https://apnews.com/article/d2e3b975b83640dd87276df7a559d559
 Koerner v. Bhatt, N.J. Super. (Law Div. 2017).
 Greenberg v. Montefiore New Rochelle Hospital, No. 2022-02194 (N.Y. App. Div. March 31, 2022).
 Crouse-Irving, 485 NYS2d 443 (1985).
 Crouse-Irving, p. 104, quoting Matter of President Directors of Georgetown Coll. 331 F.2d 1000, 1009.
 957 N.Y.S.2d 167 (N.Y. App. Div., 2nd Dept. 2012).
 Rankin, D. (2020). The Cost of Religion. Texas Review of Law & Politics, 24(3), 529-562, citing Williams v. Bright, 230 A.D.2d 548 (1997)